SHOT Annual Report 2009 - Serious Hazards of Transfusion

Table 10
Cumulative mortality/morbidity data 1996–2009
NB TACO, TAD and autologous are new since 2008, and HSE and I&U were separated from IBCT in 2008
Total IBCT I&U HSE
ANTI-
D †
ATR HTR TRALI TACO TAD PTP
TA-
GvHD
TTI
AUTOL-
OGOUS
Death in which
transfusion
reaction was
causal or
contributory
Major
morbidity
probably or
definitely
attributed to
transfusion
reaction
(imputability
2/3)
Minor or no
morbidity as
a result of
transfusion
reaction
Outcome
unknown
138 27 4 0 0 19 11 42 5 0 2 13 15 0
495 116 3 0 25 58 48 165 18 1 13 0 48 0
5998 3439 161 335 361 1154 383 50 29 4 34 0 6 42
15 11 0 0 0 3 1 0 0 0 0 0 0 0
TOTAL* 6646 3593 168 335 386 1234 443 257 52 5 49 13 69 42
*Total excludes 7 cases from 1998–1999 that were not classified
†
Cases with potential for major morbidity included in the Anti-D data are excluded from this table
OVERVIEW OF 2009 RESULTS
Transfusion-related mortality and major morbidity
There was 1 death reported in 2009 which was considered to be directly due to the transfusion: this is a proven case
of transfusion-transmitted Pseudomonas koreensis infection in an elderly man undergoing palliative care for rectal
carcinoma.
There were a further 12 deaths in which the transfusion contributed to a varying extent to the death of a patient who
was already very unwell. These consisted of 3 Incorrect Blood Component Transfused (IBCT) events resulting in ABOincompatible
transfusion, 2 inappropriate and unnecessary (I&U) transfusion (over-transfusion), 1 acute transfusion
reaction (ATR), 2 transfusion-related acute lung injury (TRALI) and 4 transfusion-associated circulatory overload (TACO).
Patients developed major morbidity from all of these categories of event, and the details are listed below and discussed
in the relevant chapters. The total number of cases of major morbidity for 2009 is 73, plus 127 cases of potential major
morbidity from late administration or omission of anti-D.
Incorrect blood component transfused (IBCT)
A total of 282 cases are included in this category, representing a further increase in reports of 7.6% since 2008. (Cases
of I&U and handling and storage errors (HSE) have been analysed separately since 2008.)
5. Summary of Main Findings and Cumulative Results 17